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12-1413 (BLCK)
lc; P.O. BOX,1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number:12='00001:4-13 Property Address: 5.153.5 AVENIDA OBREGON APN: 773-123-013-3 , -000000- Application description: WALL/FENCE Property Zoning: COVE' RESIDENTIAL Application valuation: 9-96 Applicant: Architect or Engineer: BUILDING & SAFETY DEPARTMENT BUILDING PERMIT VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 12/06/12 Owner:, JOHN BRASEL 51535 AVENIDA OBREGON LA QUINTA, CA -92253 -------------------------------- contractor: pwner .. LICENSED CONTRACTOR'S DECLARATION - p"' - WORKER'S COMPENSATION DECLARATION . • - Thereby affirmunder penalty of perjury that I amlicensed under, provisions'of. Chapter 9 (commencing with - I hereby affirm under penalty^of perjury one of the following declarations: •. Section 7000) of Division 3 of the Business and Professionals Code, and 'my License is in fullforce and effect. _ I have and'will maintain a certificate of consenYto self-insure.for workers' compensation, as provided . License Class:+* License No.: - _ for. by Section 3700 of the,Labor Code -for*,the' performance,of the work for which this permit is - - - issued:~ .. •'r . s •C s' --r Date: Contractor. II - - _ I have and will maintain workers' compensation.insurance ;,as required by Section 3700 of the Labor « Code, for the performance of the work for which this -permit is issued. My workers' compensation OWNER -BUILDER DECLARATION I hereby affirmmmp 'undei penalty of,perjury that I a'exet from the Contractor's State,License Law for the following, reason (Sec. 7031.5,,Business and.Professions Code: Any city or countythat requires a permit to construct; alter improve; demolish,.or repair. -any structure„prior to its, issuance, also requires the applicant for the rt - pePm'to file a signed statement that -he or she is*licensed pursuant.to the provisions of the Contractor's3State License Law_IChapter 9.Icommencing with Section;7000).of Division;3 of,the'Business and Professions Code' or that he or she-is'axeImpt therefrom and thebasis for the• alleged,exempuon. ,Any. violation of Section 7031.5 by X - a phcar t fora permit subjects the applicant to a civiljpenalty of not,morethan, five; hundred ;dollars ($50,6):: ; • ' 1” ,� I as owner of•the property..-or'myemployees with' wages,as their sole'compensation will'do the work, and ;the structure is not n nCed'or offered forsale (Sec:•7044, Business and Professions Code: The - Contractors! State. License'Lauv does not apply -to anowner:of property who'buildsorimproves thereon, and'who does the work himself or herself;throtigh,his or her own employees;.:piovided'that th_ e ` - improv emenmare not ioiended'or'offered-for sale. If, however, the building;or improvementsold within is sowithin one•y-ear of completion, the owner- builder will have'the burden of proving that he -.or she did not build or improve,,for the purpose of sale.). - - 1, as owner of the property, am:ezclusively contracting with licensed contractors to construct the project (Sec. r •-7044; Business and Professions Code; -The Contractors' State License'Caw'does not apply to an,owner of property, who builds or, improves thereon, and who contracts for the projects with a contractor(s) licensed . pursuant 6o the Contractors' State License Law:). - - (=) I am'exempf under Sec. B.&P.C. for this reason ate: ' CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued ISec. 3097, Civ. C.). Lender's Name: Lender's Address: / LQPERMIT insurance carrier and policy number are. Carrier - - ° Policy Number'~ - 1 certify that, inthe.performance of the work for. which this permit is issued; I shall -not employ any' - .. person.in any manner'so•a-s�to become subject to,the workers} compensation: laws, of California,,. and agree that, if 1 -should -become subject to the workers' compensation provisions 'of Section 3700 of the Labor Code, l -shall forthwith comply with those.provisions:' 7 Date pplicam: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE. IS UNLAWFUL; AND,SHALL SUBJECT.AN EMPLOYER -TO -CRIMINAL PENALTIES AND,CIVIL FINES UP MONE°HUNDRED THOUSAND , DOLLARS.($ 100,000)• IN ADDITION.TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED -FOR IN " SECTION'3706 OF THE LABOR CODE, INTEREST_AND ATTORNEY'S FEES. y ' APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby. made to the Director of Building and Safety for a permit subject.to the.rf;& < conditions and,restrictio'ns set'fortti on this apptjcation. - 1.. Each person upon whose behalf this application is made, each person at whose request.and for, whose benefit work is performed under orpursuant to any permit issued as a _result of this application;" the owner, and the applicant, each agrees to, and shall defend, indemn iy and hold harmless the City of La Quinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. 2. Any permit issued.as a result of thisapplication becomes null and voidif.work is not commenced within'180days from date of issuance_ of suchpermit, or cessation of work for 180 days will subject permit to cancellation. certify that I have read this application and state that the above information is correct. I agree to comply with all - city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. DD:. ignature (Applicant or Agent): �� Application'Number . . . . 12-00001413 Permit. . . . . WALL/FENCE PERMIT Additional desc . Permit Fee . . . . 25.00 Plan Check Fee .00 Issue Date . . . . Valuation 996 Expiration Date 6/04/13 Qty Unit Charge Per Extension BASE ,FEE 15.00 5.00 2.0000 HND BLDG�501-2;000 .10.00 Special Notes and' Comments 42 LAT. "5' .GARDEN', WALL WITH• (2): 12." % 12.1! COLUMNS:;,'CITY STANDARD. 2010 CODES. -- ------ ------------- - - ---------- - ----------- - - - - -- ------------------ Other Fees BLDGI STDS. ADMIN (SB1413)` - '1.00:' .Fee summary Charged ;Paid. Credited Due Permit.'Fee:,.Total . 25.00 .00 .00 25.00 Plan Check>"Total '.00 .00 .00 _00 Other'Fee•Toial'. 1.00 .00 .00 X1.00 Grand::Total 26..00 ', 00 .°00 26.00 t LQPEPMIT Bin # * City. of La Quinta° ivision . Building ff Safety, Division." P O'B& 1504;:'78 495.Ca!(e Tampico. La.Q' * ta, CA'92253. (760} 777-7012 Bui(di%Permit A Offc4d& and Tracking Sheet Permit # Project Address: (.3� `© ' �/� Oamer's Name:. v ' A. P. Number. Address: Legal Description: City' ST ZiP : • / Contractor. } Telephone _3 / O — FRI. §; Address: Project Description: City, ST, Zip: KJ ©� Telephoner ., y State Lie. # Arch., Engr., Designer. 2 Z Address: City., ST, Zip: `. Telephone:�a State Lia #: fes. : ., `»flu ..<N Name of Contact Person: ; Construction Type:. Occupancy: Projecttype(circle.one),. New •Add'n Alter Repair Demo Sq. FL; it Stories:' #Units. 77 Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NUT WRITE, E.LOW THIS'UNE N Submittal Req'd ' . = ReNd . ',. '. TRACKING , PERMIT FEFS Plan Sets Pian Check submitted." ItemAmount Structural Caics. Reviewed, ready for corrections Plan ChcckDeposit. . Truss Calcs. -Called Contact Person Plan Check'Balance _ Tide 24 Cales. Pians picked.up Construction • Flood plain plan Plans resubmitted.. Mechanical Grading plan . 2'+ Review; ready for correctionsfissue Electrical Subcontactor, List Called Contact Person Plumbing Grant Deed `Planspicked up H.O.A. Approval .Plans resubmitted - '.Grading IN HOUSE:- ; 1i° Review, ready for corrections issue Developer Impact Fee Planning Approval Called Contact Person A LP.P. Pub. Wks. Appr 3 Date of permit issue School Fees Total Permit Fees . 0 P.O. BOX. 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE.TAMPICO LA QUINTA, CALIFORNIA 92253 a BUILDING & SAFETY DEPARTMENT PROPER` Y O WNER' S ' PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures &Forcers for Owner -Builders Applyin g.for Construction Permits MIOTIC T[I PR(iFARD O—WnR I?ear Frxiperty owner .'An. application for a building permit has beenis your name .listing yourself as the builder of Ilre . property Imptxrvemeets specified,at We ane providing you an'Owner-Bu iA►cttaowledgogent-and [nfoimatien Verifieatiea.Form to make you aware of your �es r Possible risk you racy incar by lavrrt tfitsperunt rssued n>E:your nanaa as the Oe+aes-BkWder. We vv l not lssiie' s' f Idl;_06i& uaW year- Wive read, yoW. understands of each_ prw4sion, signed, and returned this torn to us at our oilidst address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior appioval of the permitting authority, Read is or very t#is information. I. 1 understand a frequent practice of unlicen.9ed persons is to have the property owner obtain an "Ower -Builder" building permit that erroneously implies:tlral the property, owner,is providing his or her own labor and material personally. 1, as an Owner -Builder, may be held liable ansubject to. d serious financial;risk for. any injuries sustained by an unlicensed person and his or her employees while working on my property.. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers .on my property- 2- I understand building permits are not required.to 'be signed by•property owners unless they are responsible for the construction and are not hiring a~licensed Contractor to assume this res; ponstbi4ty_ J11 understand as an,"Owner-Builder' I: am t13e; reiponsible.party.of record on the,pq-mit_ I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. J4.1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 5.1 understand if I "employ or otherwise engage any persons, other than California .licensed Contractors, and the total value of my construction. is at least- five hundred' dollars ($5.00) including -labor and materials, I may be considered an "employer" under state and federal law. ' J B .6. I understand if I am considered an "employer" .under state and federal taw, I must register with the state and federal government, withhold 'payroll takes, provide wvikc rsl, cbmpensation `disability insurance, and contribute to unemployment compensation for each "employee." 1 also understand my "iailure to.abide by these laws may subject me to serious financial risk. J_13-7.1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot .legally build .them with the .intent to .offer them for sale, unless: all work is performed by licensed subcontractors and the number of 'structures does notexceed• four' within any calendar year, or all of the work is performer under contract with a licensed general building Contractor. _ A I understand as an Owner -Builder if I sell the property for which this pemut is issued, I may be held liable for any financial or personal. i`t(ytuies sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. J'5 9.1 understand I may obtain more information regarding my obligations as an "employee" from the Internal Revenue Service, the Unitod States Small Business Administration, the California Department of Benefit Payments. and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1- 800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. .JB 10- I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the ply legally and financially responsible fos proposed construction activity at the following address: agree that, as the party legally and financially responsible for this proposed cgnstruction activity,.I will abide by all applicable laws and requirements that govern Owner-Huitders as well as employers. JF) 12.1 agree to notify the issuer of this form immediately of any additions; deletions, or d*nges to any of the information 1 have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you couttract with somoone who does not have a lieease, the Contractors' State Lionise Board may be unable to assist you with any financial loss you may sustain as a result of a complainL Your only remedy against unlicensed Contractors may be in`civil Court. It is also important for you to: understand that if an UJIUCOMW Contractor OF employee of that individual or firth is injut;ed while vrorlting on your property, you may be held Wd& for damages. If you obtain a permit as Owner -Builder and wish to hire Contrtors, you will be mWons-ble for verdying whedim or not those Contractors are prepe&Jy lieeosed and the status of dei' workers' ooation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issa#ug.Ow. permtt. Nota: A copy of dic properV owner's Mver'>dlha&r fam n@tM*RdM or other verification aceeptWe to the agency is required to be presented when the pemdt is i0uci to vw* the PMPeM owner's signature. Signature of property owner Date: Note: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder. AUTHORIZATION OF AGENT TO ACT ON )PROPERTY OVV ZWS MR&L-F Excluding the Notice to Property Owner, the excWtion of which I understand is my personal responsibility, l hereby authorize the following person(s) to act as my agents) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work):, Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: U-3 0 �Nm tZ �S A, • 32 I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the perm' ' issued to veri71heproperty o er`'-s ssignature. Property Owner's Signature: Date: 1� - 'M ow .. DRAWN CHECKED DATE SCALE JOB NO. SHEET �OF SHEETS ;i ff tvVSkH If s 'M ow .. DRAWN CHECKED DATE SCALE JOB NO. SHEET �OF SHEETS ;i